Prevention and Conversion of Post Cardiac Surgery Atrial Fibrillation: A Systematic Review of Antiarrhythmic Interventions

Context

Atrial fibrillation (AF) is a common complication following cardiac surgery and has a significant impact on symptoms, hemodynamics, morbidity, and health-care costs. There is no consensus on the optimal use of antiarrhythmic interventions for the prevention and treatment of post-cardiac surgery AF (PCSAF).

Objectives

A qualitative systematic review was conducted to determine the most effective currently available antiarrhythmic agents for the prevention and pharmacological conversion of PCSAF.

Search Strategy

Articles indexed in MEDLINE (1966 to present), EMBASE (1988 to present) and CURRENT CONTENTS and reference lists of identified articles and review articles were searched.

Selection Criteria

English language trials describing the use of antiarrhythmic drugs for the prevention or treatment of PCSAF were identified and reviewed.  Exclusion criteria included previously published data, data published only in abstract form, unpublished data, and studies including only agents not available in Canada.

Data Collection and Analysis

Three reviewers independently extracted data and assessed the quality of the trials based on an arbitrary levels of evidence scheme.

Main Results

Fifteen published prevention trials were identified and 10 involved a prospective (P), randomized (R), placebo-controlled (PC) design.  Sotalol (NNT=3), and oral amiodarone (NNT=8) were more effective than placebo as pre-op/post-op prophylaxis.  Sotalol (NNT=8-9) and IV amiodarone (NNT=8) were more effective than placebo as post-op prophylaxis. Nine published treatment trials were identified and 3 were based on P, R, PC trials.  Ibutilide was the only agent significantly more effective than placebo at converting AF to normal sinus rhythm.

Conclusions

There is a lack of well-designed clinical trials examining the use of antiarrhythmic therapy for the prevention and treatment of post-cardiac surgery AF.  Both sotalol and amiodarone initiated pre- or post-operatively reduce the incidence of PCSAF.  Only ibutilide effectively converts PCSAF to NSR.  Prophylaxis studies comparing antiarrhythmics to beta blockers or evaluating antiarrhythmics plus beta blockers, and adequately powered treatment studies evaluating IV procainamide, IV amiodarone, and oral propafenone are needed.

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